Documentation of Care Review

The objective of performing periodic documentation of care reviews is to evaluate the quality and appropriateness of PCPs’ office medical records documentation and to promote continuous improvements. Documentation is an important element in evaluating care and safety and promotes the delivery of continuity of care.

Documentation of care (DOC) reviews evaluate medical records and do not define standards of care or replace a physician’s judgment. They are performed on random samples of medical records annually. After a DOC review, Health Options will conduct a detailed follow-up with providers who have results less than 100 percent of documentation standards. Physicians will be notified in writing of deficiencies identified during the review, if applicable. Health Options will also provide guidelines and educational tools so physicians can improve medical records documentation.